Lord Burnett: My Lords, it is a pleasure to follow the noble Baroness, Lady Fookes, and to be followed by the noble Baroness, Lady Browning, because they are both loyal and compelling supporters of the Armed Forces and the three of us had the privilege of representing Devonshire constituencies in the other place.
I congratulate the noble Earl, Lord Attlee, on securing this debate. I draw the attention of the House to my entry in the Register of Lords’ Interests and to the fact that I had the honour to serve in the Royal Marines.
The Afghanistan conflict was as hard and perilous as any that the British Armed Forces have faced since the Korean War in the early 1950s. Our Armed Forces exceeded the high expectations that we always have of them. They were extremely patient, brave and restrained. They showed great stamina and fortitude and the whole country was really proud of them and their achievements. However, those achievements came at a terrible cost, with service men and women killed in action, wounded, or seriously wounded. The Royal Marines, though only about 3.5% of the Armed Forces, accounted for 13% of those killed in action and 16% of those seriously wounded. Over 30% of the decorations for gallantry in Afghanistan were awarded to the Royal Marines or former Royal Marines serving as Badgemen in UK Special Forces.
I am extremely grateful to the chief executive of the Royal Marines Charity, the superb Mr Jonathan Ball, for his assisting me ahead of this debate and for the information he provided me with. The points I shall make are of course relevant to all branches of the Armed Forces, which have also suffered similar, terrible casualties. I wish also to pay tribute to the doctors and all the medical staff in Afghanistan, unsung heroes who saved many lives and literally brought some men back from the dead; and to the helicopter crews who time and again put their lives in peril, especially when called upon to evacuate casualties. Many owe their lives to them. One dreadful consequence of this war has been the terrible price that our service men and women have had to pay in death, wounds and injury. As a country, we owe so much to them. Only the best is adequate for them.
I shall set out the deficiencies of which I am aware. I know that the Secretary of State, Mr Gavin Williamson, and his two Ministers of State, the noble Earl, Lord Howe, and Mr Mark Lancaster, give the highest priority to these matters. First is the provision for transfemoral—that is, above the knee—amputees. In 2015, Blesma, the Limbless Veterans—previously called the British Limbless Ex-Servicemen’s Association—and the Royal Marines Charity commissioned a Royal Marine triple amputee, John White, to write a report on this matter to be submitted to the Government on behalf of approximately 60 veterans from the Afghanistan campaign. Transfemoral amputees face distinct psychological challenges: they cannot use their leg muscles at all and therefore place  extreme strain on their back muscles and spines. This leads to change of weight and stump shape over time. Properly made and well-fitted sockets are therefore vital to being able to restore independence and dignity to these severely wounded men. If you do not have perfectly fitted sockets, you get sores, so you do not wear them and so you do not walk.
The report engaged with the fact that veterans were not funded to source treatment and the manufacture of sockets overseas, since the National Health Service will not fund overseas treatment as it cannot be guaranteed. However, despite the creation of the Murrison centres around the UK—which have certainly improved provision massively for below-knee amputees—we simply do not have enough transfemoral amputees to warrant having experts in the UK who can make sockets that are up to scratch. The expertise does exist in the United States, however, and Royal Marine charities—and, I suspect, other service charities—have been paying to send their men to the Hanger Clinic and to Dream Team Prosthetics in Oklahoma at a cost of about £100,000 for a set of sockets and Ottobock legs. The legs come with a three-year guarantee. As I said, I presume that other service charities are paying out the same.
The report requested that veterans be allowed to source prosthetics and sockets overseas to ensure that adequate sockets could be procured. It was presented to Mr Mark Lancaster, the Minister of State, who engaged with the NHS head of procurement to get a commitment from the NHS to pay for advanced prosthetics for these amputees, at the cost of £70,000 a pair. This is a significant achievement, and great credit goes to Mr Lancaster. However, there are still not the skill-set manufacturers of sockets in the UK of a standard that most severe amputees require, so our marines and others are still going to the US at the relevant charities’ expense. In theory this means that the NHS will not pay for the provision of legs if they are fitted to sockets made elsewhere. This has led to the absurd situation of marines and others accepting substandard sockets from the NHS, made at considerable expense, so that they can get the NHS to pay for a new set of prosthetics rather than ask the charity to pay for them to go to the United States. They then simply take the sockets off and replace them with sockets made in Oklahoma. That is a complete waste of money. The solution is that the NHS, in exceptional cases, should be funding the manufacture of sockets overseas, which will cost about £17,000 to £20,000 repair.
The Government’s preferred solution is osseo- integration —that is, the fitting of prosthetics directly to the remaining thigh bones, as a one-off expenditure. However, this is exceptionally risky as it is a relatively untested solution. If it goes wrong, it can leave a veteran crippled, with no alternative solution possible. There are photographs available for Ministers to see of osseointegrated legs which have bent under body weight. Until this solution is properly evidenced and agreed, there should be the option of doing what our above-knee amputees do.
Secondly, I will say a few words about modifying houses for the physically disabled. The MoD is committed to funding modifications to houses for serving and transitioning medically discharged veterans a maximum  of three times. However, needs change over time. Local authorities and the charities are left to fund future adaptations, as the veterans age and inevitably deteriorate over time. There should be a lifetime commitment to support such medically discharged veterans who have lost their health as a result of service.
Thirdly, I will touch on the plight of those with mental illnesses. In April 2017, the new NHS transition, intervention and liaison scheme was launched, which was intended to ensure that those medically discharged with mental ill-health issues were seamlessly transferred to NHS mental health care. In the process of tendering for the cheapest providers, Combat Stress lost a significant amount of government funding because the contracts were awarded to cheaper providers. This caused a cash crisis, thereby damaging Combat Stress’s ability to support those who had already left the service. This has meant long Combat Stress waiting lists of up to eight months before a referee can attend a residential course of treatment. The cheapest provision can of course mean very thin provision, and it is patchy across NHS regions, leading to long waits and the NHS referring cases to charities at their cost. Treatment includes, for example, eye movement desensitisation and reprocessing. This is apparently the most amazing process, as it programmes the brain away from traumatic memory. It costs about £750 for a course with a therapist local to the veteran. It is not expensive or difficult, and this provision should be replicated.
Lastly—I must not take too long over this—I turn to the Armed Forces compensation scheme. Since 2015, Royal Marines charities and others have employed people to assist marines who have received poor and inadequate Armed Forces compensation scheme settlements and face discharge from the Hasler Naval Service Recovery Centre. For the last three years, it has assisted veterans who have already been discharged. Last year, it dealt with 64 cases in the Royal Marines community alone, in each case winning an increased lump sum and often increased graduated income payments.
Service personnel of all ranks and experience, serving and veteran, do not have the knowledge or experience successfully to navigate the claims process and challenge veterans agency decisions that go against them. A root-and-branch review of the default position being adopted by the Armed Forces compensation scheme must be made. The default position should not be that the least possible compensation should be paid. In addition, the MoD should commission a study into the different levels of compensation available through the civil courts, as opposed to MoD claims, and increase the compensation to civilian levels if the MoD falls short.
I hope that the whole House will agree that only the best is good enough for our service men and women. This country—every one of us—owes them a debt of honour which we can never repay.